Medicolegal Issues

SHM Behind the Scenes


Remember the classic episod-es of “Star Trek” where a new cast member went on a mission? Chances were that guy would be the one to fall off a cliff or get zapped with a laser gun and would not make it back safely to the starship Enterprise.

Recently I was in a meeting focused on what happens when older adults are discharged from the hospital. I thought to myself: “Those are the patients wearing the red uniforms. But what if we could make the experience of older adults more like that of Spock and Captain Kirk, where luck and good preparation are on their side and the data to make informed decisions follow them everywhere?”

The transition of patients in and out of the hospital has become a key patient-safety concern. Patients frequently arrive at the hospital with incomplete medical histories and uncertain or missing medication lists. During a typical hospitalization, patients receive less than optimal preparation before their discharge and often leave the hospital without a clear understanding of how to care for themselves, identify new symptoms that require immediate medical attention, or take their medications. Further, it is often unclear whom patients should call with questions while they are in “the white space”—that time period between hospital discharge and follow-up care. Do they call the hospital? The hospitalist? Their primary care physician? Their cardiologist?

Safety related to transitions of care is a concern frequently raised about the hospital medicine movement. The use of hospitalists forces physician discontinuity at admission and discharge. However, SHM plans to make discharge planning an issue that brings hospitalists and hospital medicine the greatest praise. SHM is taking a clear, proactive leadership role to define safe transitions, create toolkits for hospitals to improve their current transition practices, and develop technical assistance programs to build quality improvement capacity at local institutions.

SHM has for years distinguished its educational offerings by offering “implementation education.” We focus on translating best practices into actual practices.

Safe Transitions

SHM is participating in two major initiatives to define safe transitions. As a member of the American Board of Internal Medicine (ABIM) Foundation Stepping Up To The Plate Initiative (SUTTP), we are helping to develop sets of principles of and standards for safe and effective transitions.

SHM also co-chaired a Transitions of Care Consensus Conference (TOCCC) in partnership with the American College of Physicians and Society of General Internal Medicine. The TOCCC further reviewed the work of the SUTTP conference and focused more specifically on issues that arise as patients transfer in and out of the hospital.

In these meetings and others, SHM’s messages were clear:

  • Improvements in transitions are needed now, and shouldn’t wait for other movements such as creation of medical homes or national electronic medical records to become a reality;
  • Safe transitions require teams of medical professionals on both sides of the transfer and patients and their families working together;
  • Patients and their families/ caregivers must be included and prepared for transfers of care;
  • Better information on patient history and medications needs to follow patients into the hospital; and
  • A small subset of information from the care plan, or transition record, should follow patients through each transfer, and be made available to them in lay terms.

Both the SUTTP and TOCCC documents are under review for endorsement by multiple medical professional societies. SHM is pursuing the development of related performance measures for safe care transitions.

Technical Assistance

SHM has for years distinguished its educational offerings by offering “implementation education.” We focus on translating best practices into actual practices. To that end, with generous support from the John A. Hartford Foundation, we are developing a discharge planning toolkit.

The toolkit will provide a step-wise approach to plan, implement, and evaluate interventions to improve discharge planning. The toolkit will help quality teams establish goals, garner internal support for interventions, educate support staff, and evaluate their results.

The interventional approaches and tools are focused on:

  • Improving communication among sending and receiving physicians;
  • Better preparing patients for post-discharge medication management and other self-care; and
  • Facilitating follow-up care and transfer of patient information.

On Sept. 7, SHM convened an advisory board in Chicago to review and provide feedback on our proposed interventional strategies, technical support offerings, and evaluation plan. An impressive group of key stakeholders attended, including:

  • Representatives from major payer groups such as the Centers for Medicare and Medicaid Services, Blue Cross Blue Shield, and Kaiser Permanente;
  • Professional societies including the American Geriatrics Society, the Society of General Internal Medicine, the Case Management Society of America, and the American Society of Health System Pharmacists.
  • Representation from the John A. Hartford Foundation, patient advocates from The Families and Health Care Project, and leaders and practicing professionals in nursing, social work, case management, patient advocacy, geriatrics, primary care, quality improvement and, of course, hospital medicine.

While not at the September meeting, the advisory board also includes representatives from the Agency for Healthcare Research and Quality and the Joint Commission.

The advisory board provided valuable feedback on SHM’s proposed toolkit and applauded our efforts to lead teams to make substantial local hospital improvements. Participants also had the opportunity to share existing resources and strategize opportunities to encourage wide-scale adoption of the toolkit. In February the advisory board plans to reconvene to review the completed toolkit.

SHM is developing training opportunities for institutions adopting the toolkit, designed to meet the full spectrum of technical assistance needs. The full toolkit will be available free on SHM’s Web site in the spring. At the April 2008 SHM Annual Meeting in San Diego, quality teams can participate in a daylong pre-course on general quality improvement principles and hands-on application of the toolkit.

In May, SHM will begin reviewing applications for sites wishing to participate in the yearlong mentoring program or a more intensive short-term, on-site consultant service. For more information on these technical assistance programs, visit the SHM Web site at and select the “Quality Improvement” link, then “Current Initiatives.”

We hope you and your institution will join our journey into the white space to improve discharge planning and help our patients “live long and prosper.” TH

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